Identify five nursing interventions related to these side effects to include in C.O.'s plan of care
What will be an ideal response?
• Perform assessments for:
• Pulmonary edema: dyspnea, crackles, unproductive cough, chest pain, tachypnea, fatigue,
increased pulse, pallor, lethargy
• Hepatotoxicity: jaundice of skin, sclera, dark urine, clay-colored stools, pruritus, abdominal pain,
fever, diarrhea
• Neuropathy: gait disturbances, paresthesia, numbness
• Laboratory results as available before and during therapy:
• Renal studies: blood urea nitrogen (BUN), serum uric acid, urine creatinine clearance, electrolytes
• Hepatic studies: bilirubin, alanine transaminase (ALT), aspartate transaminase (AST), alkaline
phosphatase
• Maintain intake and output (I&O) ratio; report fall in urine output to less than 30 mL/hr
• Increase fluid intake to 2 to 3 L/day unless contraindicated
• Initiate bleeding and infection precautions
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An adolescent patient at a pediatric clinic presents with a butterfly rash. What diagnosis does the nurse suspect?
a. Tuberous sclerosis b. Eczema c. Psoriasis d. Systemic lupus erythematosus
A patient receives a neuromuscular blocking agent before a procedure. The patient's eyes close. The nurse knows this is a sign that the patient:
a. has fallen asleep. b. has received a toxic dose of the medica-tion. c. is beginning to feel the drug's effects. d. may need mechanical ventilation.
A client has an elevated level of urinary microalbumin. The nurse under stands this could be an indication of:
A) Addison's disease. B) pancreatitis. C) diabetic nephropathy. D) thyroid cancer.
Alice Powers has been a parish nurse for 1 year and is trying to establish a health program that is balanced across all levels of prevention (primary, secondary, and tertiary). An example of a primary health intervention she might consider would be
1. Arranging for a mobile mammography unit to come to the church to provide low-cost mammograms. 2. Organizing a support group for widows and widowers. 3. Providing vaccinations against influenza for older parishioners. 4. Setting up a system that would facilitate referrals to community providers.